Failure to Provide Ordered and Menu-Listed Beverages With Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide beverages as listed on menus, as ordered, or per resident preferences during meals for multiple residents. For one resident with dysphagia, mechanically altered PO intake, and cerebral palsy, the lunch meal ticket specified hot coffee or hot tea, but no beverage was served with the meal. The resident, who had intact cognitive abilities and could use utensils to bring food and liquid to the mouth, reported not receiving anything to drink with lunch and indicated he would drink from his personal water bottle instead. Facility leadership later acknowledged that the meal ticket should have been followed and that beverages should have been available. Another cognitively intact resident with a diagnosis including moderate protein calorie malnutrition reported poor service from nursing and dietary staff. At lunch, the resident’s meal ticket listed hot tea or coffee, but no beverage was present on the tray other than what was already on the bedside table. The resident was heard asking an LPN for his tea or coffee; the LPN shrugged, left the room, and did not return with a beverage. The Dietary Manager later stated that the residents should have received their beverages. Two additional residents did not receive beverages in accordance with the menu and their personalized meal tickets. One resident with stroke, renal failure, and heart failure, and with moderately impaired cognition, had a lunch meal served without any fluids, despite the menu specifying an 8 oz and a 6 oz beverage at lunch and the resident’s ticket allowing one 8 oz beverage due to a 1200 ml/day fluid restriction. The following day, this resident again received a lunch meal with no fluids served. Another resident with tracheostomy, diabetes, PVD, and heart failure, and intact cognition, was served lunch meals on two consecutive days without any fluids, even though the menu called for an 8 oz and a 6 oz beverage and the meal ticket specified 2% milk (8 oz) and hot coffee or tea (6 oz). The Dietary Manager explained that beverages had been removed from trays due to spilling and were being sent separately, and that he was unaware residents were not consistently receiving beverages as planned. Across these cases, surveyors observed that residents did not receive beverages as listed on the menu or meal tickets, or as ordered, during lunch meals. Staff interviews confirmed that meal tickets should have been followed and that beverages were expected to be provided with meals. The Dietary Manager acknowledged that drinks were being sent separately from trays due to spill concerns and that there was an error in the menu software offering milk at lunch, while also stating that no concerns had been raised to him about residents not receiving beverages according to the menu, preferences, and physician orders.
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